Introduction
Bruxism is a common occurrence observed in our patients. Frequently, those patients do not seek treatment until significant wear has occurred, often only when sensitivity presents, leading them to finally seek treatment.
Clenching and bruxism are conditions that have been linked to stress levels, with an increase in incidence in individuals with greater stress levels.1,2 This becomes a habit that compromises the teeth and associated structu
res over time. As the clenching and bruxism become chronic in nature, wear of the teeth is frequently noted.3 Additionally, some patients may exhibit these issues with acute episodes of stress and anxiety.4 The literature has reported a frequent occurrence of bruxism during sleep, which may be stress related with patients grinding more often following a stressful day.5 This is also prominent in those patients with obstructive sleep apnea.6
Psychological factors associated with bruxism, other than anxiety, include depression, sociability, stress coping, and personality traits. While bruxism has traditionally been identified and treated as a nighttime issue, many patients also experience it during the day. Awake bruxism is associated with significantly higher levels of anxiety and stress and may play a role in stress coping as a way of relieving psychological tension. Although we have typically identified and treated patients who exhibit this during sleep, many patients exhibit this when awake. Awake bruxism demonstrates a high prevalence and a positive association with signs and symptoms of temporomandibular disorders (TMD) and poor sleep quality.7 That awake bruxism group presents significantly higher levels of the trait and a higher state of anxiety related to their stress levels.8 A positive relationship has been found between awake bruxism and levels of anxiety, but not between sleep bruxism and anxiety.9 Additionally, bruxism has been associated with increased tooth wear, fracturing of teeth or restorations, and overall decreasing quality of life in those patients suffering from it.
Bruxism creates a loss of tooth structure, resulting in the vertical dimension of occlusion (VDO) being reduced, resulting in aesthetic and functional changes for the patient. Utilizing a “no-prep” approach allows conservation of the remaining tooth structure and the planned restorations being bondable to restore the VDO, creating interarch space to improve the patient’s aesthetics. Additionally, re-establishment of the VDO decreases stress on the temporomandibular joint (TMJ) and its associated muscles and ligaments, improving the patient’s overall comfort. The use of 3D printing and ceramic resins, such as Ceramic Crown (SprintRay), permits virtual design of the planned restorations and a single clinical appointment to restore the worn dentition using a no-prep clinical treatment approach.
Case presentation
A 52-year-old female patient presented for recommendations on wear and associated aesthetic issues. The patient indicated that she was a “tooth grinder” and had ignored the problem for years, but is now noticing wear on her front teeth and is unhappy with the current aesthetics. She expressed that she was looking for a conservative approach to improve her smile.
The examination noted general wear of the maxillary dentition with significant wear of the central and lateral incisors on that arch (Figure 1). This resulted in an absence of occlusal contact in the anterior when the arches were occluded. Light wear was noted on the maxillary right first and second molar lingual cusps, with moderate wear on the entire occlusal surface of the right premolars and canine to canine. The posterior teeth in the left maxillary quadrant demonstrated light occlusal wear. The mandibular teeth also presented with light wear, with a flattening of the cusps and a worn reverse curve on the anterior incisors. She indicated that no significant sensitivity was present in her teeth.
The clinical findings were discussed with the patient, and she expressed that, due to budgetary issues, she wanted to treat only the maxillary arch at this time. A conservative treatment plan was presented that would involve the placement of onlays on the maxillary posterior teeth and veneers on the maxillary anterior teeth utilizing a no-prep approach. The restorations would be fabricated utilizing 3D printing with resin restorations and completed in a single appointment. The patient agreed to treatment, and scans of the arches were accomplished with a TRIOS 4 intraoral scanner (3Shape) to capture the full arches and bite for planning purposes. The patient was appointed for the treatment visit and dismissed.
The scan data was imported into 3Shape software (TRIOS Design Studio [3Shape]) to begin planning and design of the restorations. The scan of the maxillary arch demonstrated anterior wear that resulted from bruxism (Figure 2). The amount of anterior wear was evident in the virtual occluded arches, resulting in an open anterior bite (Figure 3). Lateral views of the occluded arches demonstrate a flattening of the posterior dentition bilaterally (Figure 4). Analysis of the maxillary arch from an occlusal view demonstrated the generalized wear that was noted during the clinical exam. A virtual model was designed in the software to be printed (Figure 5). Virtual models were articulated and replicated what was observed clinically (Figure 6). The maxillary model was 3D printed in Die and Model 2 Gray SprintRay resin in the P55 Pro S printer with a print time of 25 to 30 minutes on a standard platform (Figure 7). The printed models would be used when finishing the printed restorations to have them ready for insertion at the clinical appointment.
The next step was the design of the planned restorations, which was accomplished using the TRIOS Design Studio software. A facial image of the patient smiling was utilized to design how the smile would look, following veneer design on the anterior teeth to determine how much incisal length would be required to achieve that aesthetic change (Figure 8). In the design software, the VDO was raised 1.0 mm in the molar region to account for tooth wear present and allow sufficient restorative material thickness for the planned restorations. The design was placed onto the virtual maxillary arch to finalize the design of the restorations across the arch. Comparing the before and after, without the need for tooth preparation, a dramatic change was evident, restoring the teeth to a pre-bruxism appearance (Figure 9, left and middle). The virtual designed restorations were transferred to the virtual model to illustrate where restorative material would be added to those teeth (Figure 9, right). The maxillary arch was examined virtually before treatment (Figure 10, left) and after the virtual design of the restorations to replace the worn tooth structure (Figure 10, middle). It was then fully designed and ready for 3D printing (Figure 10, right). Within the software, the virtual arch was removed, leaving the virtual restorations to demonstrate what would be added to the worn teeth to restore their anatomy (Figure 11).
The restorations were then printed in the P55 Pro S 3D printer with the Crown Kit platform using Ceramic Crown resin in shade B1 (Figure 12). Following the printing steps, the printed restorations attached to the Crown Kit were hand-sprayed with isopropyl alcohol for no longer than 40 seconds, then air blown to clean and dry the overall Crown Kit surface with the 3D printed veneers. All restorations were detached from the Crown Kit and placed into the ProCure 2 curing unit (SprintRay) for 6 minutes and 42 seconds for the complete curing of the restorations. The supports were then removed and restorations were finished. The restorations were inserted on a printed model to aid in finishing and verify restoration fit on the teeth (Figure 13). Polishing of the restorations was accomplished without glaze, utilizing ceramic polishing wheels, followed by a white goat hair polishing wheel with Universal Polishing Paste (Ivoclar).
Clinical Appointment
The patient presented for the clinical appointment and a rubber dam was placed to isolate the anterior maxillary teeth in preparation for the insertion of the veneers on canine to canine (Figure 14). The veneers were tried in to verify fit and interproximal contacts to the unprepared teeth (Figure 15). The sides of the restorations that would contact tooth structure were sandblasted to create a rough bondable surface. A 37% etching gel was applied to the teeth to receive the veneers for 30 seconds and then rinsed and dried. Monobond Plus adhesive (Ivoclar) was applied with a microbrush on the intaglio surface of all restorations after sandblasting (aluminum oxide). Variolink Esthetic DC adhesive resin cement shade neutral (Ivoclar) was placed into the veneers, and they were inserted intraorally. Excess cement was removed marginally with a brush and a clear matrix strip slid interproximally to prevent bonding the veneers to each other. The veneers were light cured from the facial for 30 seconds, and then repeated on the lingual. The matrix strips were removed, and further light curing was again performed. The rubber dam was removed, and the posterior quadrants were then isolated with the rubber dam. Those restorations were tried in to verify fit to the unprepared teeth. The cementation process performed on the anterior veneers was repeated with the posterior onlays. Finishing diamonds were utilized to confirm an absence of residual resin cement and smooth transition marginally. Occlusion was checked, and adjustment was found to be unnecessary. The patient indicated the bite felt even bilaterally and was comfortable. When shown a mirror, she expressed satisfaction with the aesthetic results (Figure 16). A printed maxillary occlusal night guard was tried in and occlusion checked. The patient was instructed that wearing the occlusal guard when sleeping was important to avoid future bruxism and a need for further correction of wear (Figure 17).
Comparison of the arch following virtual planning as viewed from the occlusal is mimicked by the clinical appearance of the restored arch (Figure 18). This demonstrates the accuracy of virtual planning and 3D printing clinically when teeth are restored.
The patient has been seen for routine recall appointments over the 18 months since the placement of the restorations. No wear has been observed on the ceramic resin onlays and veneers, demonstrating the durability of the material.
CONCLUSION
The presentation of bruxism is a frequent occurrence in dental practice. This leads to tooth wear and a decrease in the VDO. Typically, the patient presents for treatment when either sensitivity is occurring on the teeth showing worn tooth structure related to that bruxism, or sometimes, they are unhappy with the anterior aesthetics and may not have sensitivity.
Virtual planning and 3D printing allow single-visit treatment of the tooth wear, restoration of the lost VDO, and improvement in the aesthetics. This is especially true when tooth preparation is not required, and onlays utilized to replace the lost tooth structure in the posterior and veneers in the anterior. Virtual planning also allows the patient to visualize what aesthetic improvement can be achieved before the finalization of the design and printing of those restorations. The ceramic resin utilized in these types of cases seems to be a good approach to potential wear. Daily utilization of a nightguard aids in the prevention of wear during sleep should the patient continue to brux.
Further long-term clinical studies are needed to assess the durability of the material in the long term and confirm the reliability of the overall process outlined in this article.
REFERENCES
- Sutin AR, Terracciano A, Ferrucci L, et al. Teeth grinding: is emotional stability related to bruxism? J Res Pers. 2010;44(3):402–5. doi:10.1016/j.jrp.2010.03.006
- Alves AC, Alchieri JC, Barbosa GA. Bruxism. Masticatory implications and anxiety. Acta Odontol Latinoam. 2013;26(1):15-22.
- Bronkhorst H, Kalaykova S, Huysmans MC, et al. Tooth wear and bruxism: A scoping review. J Dent. 2024;145:104983. doi:10.1016/j.jdent.2024.104983
- Dhaliwal G, Ouanounou A. Tooth surface loss: causes, management, and prevention. Quintessence Int. 2024;55(6):504-513. doi:10.3290/j.qi.b5223649
- Li D, Lobbezoo F, Hilgevoord AAJ, et al. Prevalence and risk factors of sleep bruxism in adults with primary snoring: a large-scale polysomnographic study. J Clin Sleep Med. 2024;20(8):1331–337. doi:10.5664/jcsm.11142
- Sambale J, Koehler U, Conradt R, et al. Is sleep bruxism in obstructive sleep apnea only an oral health related problem? BMC Oral Health. 2024;24(1):565. doi:10.1186/s12903-024-04351-1
- Hilgenberg-Sydney PB, Lorenzon AL, Pimentel G, et al. Probable awake bruxism — prevalence and associated factors: a cross-sectional study. Dental Press J Orthod. 2022;27(4):e2220298. doi:10.1590/2177-6709.27.4.e2220298.oar
- Soto-Goñi XA, Alen F, Buiza-González L, et al. Adaptive stress coping in awake bruxism. Front Neurol. 2020;11:564431. doi:10.3389/fneur.2020.564431
- Tavares LM, da Silva Parente Macedo LC, Duarte CM, et al. Cross-sectional study of anxiety symptoms and self-report of awake and sleep bruxism in female TMD patients. Cranio. 2016;34(6):378–81. doi:10.1080/08869634.2016.1163806
ABOUT THE AUTHORS
Dr. Silva holds MSc, PhD, and postdoctoral degrees from the University of São Paulo, Brazil and New York University (NYU) in New York, NY. He is a professor in the department of restorative dentistry at the Federal University of Minas Gerais (UFMG) in Brazil. He served as assistant and associate professor of prosthodontics and biomaterials at NYU for about 11 years and published books and book chapters along with high impact factor manuscripts. His clinical and research skills involve translational research; disruptive technology in dentistry; laboratory and clinical aspects for the success of cosmetic restorations; partial and complete removable prostheses; and implant therapy using CAD/CAM. He can be reached at nrfa.silva@icloud.com.
Disclosure: Dr. Silva received hardware and software from SprintRay and 3Shape to develop this article.
Mr. Kukucka is vice president, clinical removable prosthetics and design technologies at Aspen Dental, a national network of more than 1,100 dental offices. He is responsible for the delivery and clinical efficacy of removable prosthetics, overseeing and facilitating learning and development initiatives for new and mid-career doctors and digital technologies. He can be reached via email at eric.kukucka@aspendental.com.
Disclosure: Mr. Kukucka is a member of the SprintRay Clinical Advisory Board and has previously lectured and conducted research for SprintRay.
Dr. Kurtzman is in private general dental practice in Silver Spring, Md. He is a former assistant clinical professor at the University of Maryland in the department of restorative dentistry and endodontics and a former AAID Implant Maxi-Course assistant program director at Howard University College of Dentistry. He has lectured internationally on the topics of restorative dentistry, endodontics, implant surgery and prosthetics, removable and fixed prosthetics, and periodontics. He has more than 890 published articles globally, as well as several ebooks and textbook chapters. He can be reached at dr_kurtzman@maryland-implants.com
Disclosure: Dr. Kurtzman received an honoraria for writing this article.
